Paver Lighting, LLC
2500 Weston Road Suite 220
Weston, FL 33331

Ph:
954.620.3124
Fx: 954.436.1779
  Your Authorized
Evening Star ®
Distributor.
Corporate Application For Dealer

Company Name * Fed Tax ID # *
Address * Zip *
City * State *
Phone * Fax *
Type of Business * Number of Employees *
Incorporated *
Yes No
State Incorporated *
    Date Incorporated *
Subsidiary *
Yes No
Parent Company
Address Zip
City * State
Financial Statement *
Yes No
D & B Rating
    Yrs. In Business *


BILLING INFORMATION:
Bill To * Attn * Title *
Billing Address * City * City *
Account Payable * Phone * Zip *
Billing Instructions *        


NAME OF PRINCIPALS
President * Address * SS# *
Vice-President * Address * SS# *


BANK REFERENCE
Bank * Address *
Account * Contact * Phone *
Bank * Address *
Account * Contact * Phone *

ANK REFERENCE
Company * Address *
City * State * Zip *
Type of Business * Contact * Phone *
           
Company * Address *
City * State * Zip *
Type of Business * Contact * Phone *

By signing this application, you agree that Paver Lighting, LLC.. and/or an affiliate company may investigate the information supplied by you.
This investigation may include your character, general reputation, style of living, and your credit rating (as supplied by a national credit reporting agency).


Signature of Applicant * Title * Date *


CREDIT CARD AUTHORIZATION

Name *
Address *
Phone *


 
Credit Card Type *
Credit Card Number: *
Name on Card *
Expiration Date *
Verification Number *
Credit Card billing address *
Bank which issued credit card *
City, State of bank *

In the event payment is made by credit card, I agree to a 5% administrative fee.

Card holder’s signature *
Date *
     
   

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